Successful Practices of the FutureIn the rapidly changing dental marketplace, we see dental practices segregating onto three tiers. On the lower tier. there are a small percentage of practices that treat patients through managed care contracts only. The vast majority of practices reside in the middle tier; while predominately fee for service, they also have some managed care contracts. Finally, typical practices on the high end maintain a strictly fee-for-service operation, differentiating themselves on the basis of higher quality and higher fees.

Maintaining a successful practice in this higher quality tier requires a good conversion rate. The conversion rate is simply defined as the percentage of patients accepting treatment, where treatment has been recommended. The key to a good conversion rate is making patient treatment affordable. In most cases, affordability is more a matter of the patient's perception, than reality.

For example, let's review the current situation in orthodontics. Advances in treatment materials and modalities have significantly decreased treatment time for the average case. Maintaining monthly payments tied to the treatment duration has resulted in higher monthly payments. Since most patients are extremely sensitive to relatively small changes in monthly payment amounts, the doctor's ability to treat has outstripped the patient's ability to pay under these traditionally designed payment arrangements. While some doctors have sought to mitigate the problem by holding patients "hostage" until they can pay over a longer treatment period, this is both an unethical and inefficient alternative.

What's needed is a flexible payment arrangement to decrease the required down-payment and monthly payments in order to provide greater affordability. Through greater affordability, doctors can maintain or increase the percentage of patients who financially qualify for treatment and maintain a high conversion rate. The patient's perception of affordability is tied much more to payment arrangements than to price. Witness advertising for automobile and other big ticket items where down-payment and monthly payment amounts are heavily advertised and price is rarely mentioned.

Maintaining Labor Efficiency Evidencing this trend, some practices have already begun offering more flexible payment arrangements in order to maintain or increase market share. This has typically been done through creation of a "financial coordinator" position, dedicated exclusively to establishing, maintaining, and enforcing a multitude of different payment arrangements for patients. Unfortunately, this dedicated position has proven extremely costly. What's needed is a system providing a few simple, but highly effective, flexible payment options that can be administered on a low labor cost basis.

Cost-effective Patient Financing ProtocolAfter reviewing this problem and examining current and emerging alternatives, we feel the following patient financing protocol will best serve the practice's needs. These options are presented in the order that they should be presented to patients, ranging from the most cost‑effective to the least cost‑effective for the practice:

1. 5% discount for full payment up front. While we recognize that few patients will accept this, the ones that do guarantee collectability to the practice. The 5% discount is more than offset by the cost of billing and collection, and potential bad debt write‑offs.

2. Credit card pre‑authorization to pay remaining balance in lump sum. The next option presented to the patient is for the patient to charge the balance remaining after insurance payment, directly to their generalized credit card (Visa, Mastercard. American Express, Discover, etc.). This can be structured by providing space on the new patient entry form for the patient to provide their credit card type, number, expiration date, and their signature preauthorizing this charge.

3. Credit card pre‑authorization to pay remaining balance in monthly payments over an agreed upon period. In many cases, patients will not have available limits on their credit cards in order to accommodate preauthorization of the remaining balance in a lump sum. In this case, the patient can agree to preauthorize a monthly charge to their credit card in an amount, and over a time period, necessary to make treatment affordable for them. While credit card charges typically involved a discount charge of around 3% to the practice, this is more than offset by the fact that collection remains in the hands of the practice, and no further billing and collection cost is incurred.

4. Electronic bank transfers. A rapidly emerging alternative involves a patient preauthorization to electronically transfer funds from their checking account into the practice checking account in a designated amount on a designated date each month. While this technology is now available and being generally offered to doctors by third party vendors who perform this service, the newest generation of software allows the practice to access patient funds, without the use of a third party servicing vendor. If the patient has no credit cards, or lacks available space on existing credit cards, in most cases they will have a checking account which can be accessed on this basis.

5. All of the above! Set your patients up with a payment plan with Preferred Payment Plans and never again have to worry about billing, processing payments, and collections. Plus, reduce your staff labor costs significantly. Preferred Payment Plans is a payment plan management program that allows your patients to make affordable monthly payment through their credit card or bank account. Click here for more information!

Doctors that can design flexible payment arrangements for patients to increase affordability improve conversion rates and market share. Providing patients with preprinted materials discussing these flexible payment options as part of their new patient entry materials will simplify their decision making process, and eliminate the need for a dedicated employee to handle this task, thereby reducing labor costs. Implement this system of the future in your office now to boost production, reduce labor costs and significantly boost practice profitability.

Porcelain has been prized for its beauty for centuries, but the material’s relative fragility was long considered a barrier to its utility. In fact, it wasn’t until the modern era that science and technology allowed the creation of ceramics with the strength necessary to make their use in dentistry not only feasible but highly desirable.

All dental practitioners have their preferred techniques and materials, and ceramics provide no exception to this rule. However, with new materials and technology being developed every year—and with the preference for all-ceramic restorations on the rise—dental ceramics are worth another look, whether one’s practice is brand new or well established.

From Fragile BeginningsDentistry first applied ceramics in the 18th century, when Alexis Duchateau created a complete set of dentures using porcelain. Because the porcelain would not degrade in the wearer’s mouth like dentures made from human or animal teeth,1 this innovation led to exploring different applications for ceramics as a restorative material.

The evolution of dental ceramics continued into the late 1800s, when the Richmond crown, a single-piece crown consisting of a porcelain facing fused to a metal post,2 was introduced. This was closely followed by the development of the all-porcelain jacket crown by Charles Land in 1889.3 These innovations allowed the use of ceramics for restoring single teeth.

In the late 1950s, Abraham Weinstein invented a porcelain-fused-to-metal (PFM) crown. The metal substructure resolved inherent strength problems but lessened the esthetic qualities of these restorations, as the crowns were quite opaque.4 Since then, advancements in dental ceramic restorations have encompassed the material’s chemical composition, manufacturing processes, strength, esthetic properties, and indications for use—particularly where they can be predictably placed in the mouth.

“Since 1965, we’ve seen an increase in strength and fracture toughness largely due to an increase in the crystalline content of ceramic materials,” explains J. Robert Kelly, DDS, DMedSc, professor in the department of reconstructive sciences at the University of Connecticut Health Center. “From the earliest high-strength core materials that were about 55% aluminum oxide to those that were about 70% lithium disilicate, and then to those that contained 100% polycrystalline ceramics, there’s a definite period where dentistry transitioned to advanced engineering ceramics due to enhancements in powder technology and processing.”

Better Materials Through ChemistryCeramics are man-made, inorganic materials formed by heating raw minerals at high temperatures.5 Dental ceramic materials can be classified into four types by their chemical composition: glass-based, glass-based with crystalline fillers, crystalline-based with glass fillers, and polycrystalline solids. The processing methods used with each respective ceramic composition enable that material to be used in the anterior or posterior regions—or both—to restore everything from small caries and discolored teeth to larger structural defects, depending on the material’s specific indications and material properties.

“The availability of different dental ceramics helps the profession by providing us with materials for every type of restorative problem in esthetic dentistry, from conservative to aggressive,” explains Edward A. McLaren, DDS, MDS, professor, founder, and director of the UCLA Post Graduate Esthetics Program. “In some ways it can also be a hindrance to have too many choices, so it becomes essential for dentists to know the materials and their characteristics.”

Feldspathic PorcelainsFeldspars are naturally occurring crystalline minerals formed of aluminum silicate with potassium, sodium, barium, or calcium.6 Feldspars are combined with other minerals, such as quartz and kaolin, for improved esthetics and plasticity. Metals such as zinc, titanium, copper, iron, cobalt, nickel, and manganese are added for color; tin, titanium, or zirconium are added as needed for opaqueness.7

The minerals are mixed to a fine powder, then blended with either deionized water or special modeling liquid to create feldspathic porcelain paste. The resultant paste is layered and fired repeatedly to create either fully feldspathic porcelain veneers and crowns or veneers with metal, alumina, or zirconium substructures.8 Feldspathic porcelain is very brittle, and even with a strong core is only recommended for the anterior region.

“If I’m in the anterior part of the mouth with mostly enamel to bond to, that’s when I’ll use feldspathic porcelain,” says McLaren.

High-Strength CeramicsThese ceramic systems typically have a core fabricated from alumina, spinel, or zirconia that is layered with a veneering ceramic, such as feldspathic porcelain, for esthetics.9 High-alumina ceramics are extremely strong, containing a minimum of 95% pure aluminum oxide. Highly pure zirconia (99.9%) contracts at a rate of 15% to 20% during sintering, delivering a predictable final fit and form.10-12

“Today, ceramics are applied to everything from implant abutments to posterior bridges, from full-arch cases to single anterior cases,” says Ryan Johnson, chief technology officer for Dental Arts Laboratories. “The production methods and materials have improved, so we’re seeing much better performance.”

Leucite-Reinforced PorcelainsLeucite is a potassium-aluminum silicate mineral added to feldspathic porcelain through one of two processes.7 The first, incongruent melting, involves melting one material (potasic feldspar) to a different crystalline material (leucite).10 The second “low temperature” process involves adding synthetic leucite powder to feldspathic porcelain paste.

Both processes increase crack propagation strength in restorations,11 but incongruent melting forms tetragonal leucite crystals that some research suggests provide more internal structural strength than room temperature cubic leucite crystals.13 Tetragonal leucite formation is also the recommended reinforcement method for metal-ceramic restorations due to its ability to form a thermal bond with both materials,14 making the entire restoration more stable.

Lithium-Disilicate Glass CeramicsLithium disilicate is composed of silica, lithium dioxide, alumina, potassium oxide, and phosphorous pentoxide, which is melted together and then cooled. The glass is heated at specific temperatures to produce crystalline growth. When optimal crystalline growth has occurred to maximize the material’s strength, the ceramic is pulverized into powder. The powder can be pressed into ingots or processed using other techniques.15 These processes result in raw materials that are either CAD/CAM milled or heat-pressed to reach a strong, monolithic, final restoration.

“If I’m bonding to dentin or there are issues of flexural effects on bond strength, my first thought is to use lithium disilicate and be as conservative as the preparation will allow,” McLaren says.

A study in 2005 reported that more than 50% of all indirect restorations were metal ceramics.17 This was likely due to the ease with which these restorations are manufactured.18

According to Michael DiTolla, DDS, FAGD, director of clinical education and research at Glidewell Laboratories, dentists are shifting gears, however. They are voting with their prescriptions by requesting all-ceramic restorations instead of the PFM restorations that served dentistry well for the past 50 years. This is despite the fact that all-ceramic restorations were traditionally the ones that fractured the most, were the most technique sensitive when being adhesively bonded into place, and that dentists were the most reluctant to try for fear of fracture or failure, he elaborates.

Zirconia-Based CeramicsZirconia occurs as a natural mineral known as baddeleyite. The mineral comprises 80% to 90% zirconium oxide, with primary inclusions of titanium dioxide, silicon dioxide, and iron oxide. Zirconia exists in three separate crystalline phases: the monoclinic phase at room temperature, the tetragonal phase at approximately 1,200˚C, and the cubic crystalline phase at around 2,370˚C. Attempts were made to process this material similarly to other ceramics, but with limited success, because crystal transformation during the cooling process led to cracks. Engineers discovered that zirconia could be stabilized with small amounts of calcium, yttrium, or cerium, however. This advancement led to tetragonal zirconia, which was metastable at room temperature.19,20

The partially stable zirconia, or “greenware,” is then CAD/CAM milled to oversized restorations and single or multi-unit substructures for other applications,21 which are designed to compensate for the 30% volumetric shrinkage that occurs upon sintering. The requisite sintering also creates a more dense, stable, and wear-resistant restoration.22 Zirconia is becoming a standard material for use when fabricating posterior dental restorations. CAD/CAM technology provides the ability to process durable restorations at a fraction of the time, cost, and technique sensitivity of previous methods. “When ceramics like zirconia evolved, they were processed to produce high strength, but machining and shaping restorations was very difficult, so you could not conveniently use them,” explains Van Thompson, DDS, PhD, professor and chair of the department of biomaterials and biomimetics at New York University College of Dentistry. “With CAD/CAM technology and the ability to use the materials in a partially fired (sintered) state, we now have a wonderful material that can be used in a routine and cost-effective way.”

Technology and TechniqueTechnology is a driving force behind advances in ceramics. A broader range of dental ceramic restorations and processing techniques are available thanks to technological advances from other industries, as can be seen with the impact of newer computers and high-speed processors on CAD/CAM, Johnson observes. The demand for biocompatibility, esthetics, durability, and less labor-intensive processing has always been present throughout the profession (eg, eliminating hand-layering, refractory die, and foil techniques), but today’s technologies have made achieving those objectives possible, he says.

“Many years ago, dentists were limited to using all-ceramic crowns for anterior restorations,” Thompson recalls. “These had to be fabricated by hand and in layers, which was a relatively expensive process. Today we have the ability to use ceramics in the posterior that are sufficiently strong so we can get away from metal altogether.”

Add esthetics and cost to the equation, and today’s materials for all-ceramic restorations become even more attractive. John O. Burgess, DDS, MS, assistant dean for clinical research at the University of Alabama at Birmingham, says that as the costs associated with metal, gold, and high noble alloys increased, so did the use of lower cost, high-strength all- ceramic materials that demonstrated better esthetics (eg, eliminating the metal band around the gingival margins). Further, the ability to fabricate all-ceramic restorations in a monolithic form—rather than layering—yields restorations with lower chipping rates than layered high-strength core materials, he adds.

“Lithium disilicate—when used properly as a monolithic, full-contour restoration—represents a major and significant change for dentistry,” McLaren believes. “I have no reservations about recommending it as much as I would have recommended gold 30 years ago.”

According to DiTolla, the monolithic concept isn’t new to dentistry. Cast gold was the first monolithic material used in dentistry. Although many dentists might admit that cast gold is an ideal restorative material, it is highly unesthetic, and most patients are averse to having it placed in their mouths.

Predicting OutcomesConsiderations for choosing which contemporary dental ceramic to use include time constraints, the patient’s oral habits, material characteristics, and the region in the mouth where the restoration(s) will be placed. Metal-supported ceramics and zirconia restorations have been avoided in the anterior due to their opacity.

However, CAD/CAM, monolithic restorations, and refined layering techniques are providing greater predictability, durability, functionality, and esthetics across available all-ceramic restorations. Additionally, material testing prior to introduction is lending greater insight into how materials will actually perform in the oral environment under different conditions.

“We have laboratory processes that have evolved to be predictive of clinical performance, which is something we didn’t have in the past,” Thompson clarifies. “We can subject ceramics to the conditions of the teeth and oral environment and determine how they will perform. This allows us to screen for failures, resolve issues, and be predictive.”

According to Kelly, this means that ceramic materials are engineered based on what has been learned about material stress and failure, yielding better results. Additionally, processing techniques have been enhanced based on knowledge of how laboratories, clinicians, or machines can impart damage on restorations, he adds.

ConclusionIf dentists remain informed about available ceramic materials, they’ll have more choices for providing esthetic and sufficiently strong restorations for the indication at hand, says Thompson.

“There’s hardly an intracoronal restoration that isn’t now being done with ceramics,” notes Kelly. “Veneers are very robust, and anyone who has a CEREC machine in the office can perform modern, conservative restorations by relying more on bonding than on placing an aggressive crown preparation.”

In the past, new ceramic alternatives were met with questions focused on what would be sacrificed—strength, longevity, or esthetics. Today, practitioners have the option of placing all-ceramic restorations that will stand the test of time and wear—and still satisfy even the most demanding patients.

What's the secret of building a highly effective dental team? One key is to maintain good communication through regularly scheduled, well‑planned staff meetings. Unfortunately, when most staff meetings are held, it's usually because the doctor or office manager is upset with one or more staff members. What's worse, the doctor or the most controlling staff member usually dominates these meetings. As a result, staff rarely look forward to attending. Staff members frequently comment “Oh, we hardly ever have staff meetings, but that's fine with me, because we never solve anything and besides, they would never listen to my ideas or recommendations on anything.” In order to regain strong communication, commitment and enthusiasm, doctors need to change the way they conduct staff meetings. All personnel should have an equal opportunity to voice their thoughts, ideas and desires in front of all concerned parties.

How often should they be held? Generally; no less than once per month, and at a time that allows for all staff members to be present. Meetings should be held on the same day each month, so that time can automatically be blocked out.

Here are some ideas to get the maximum benefit from staff meetings:

Avoid the tendency for staff meetings to become a lecture by the doctor. Rather, this should be a time for interchange of ideas.

Try having a different staff member moderate each meeting. Staff members need to feel that their ideas are valuable, so develop an atmosphere where individual ideas can flourish.

Establish a specific agenda, and define the purpose of the meeting in advance by posting a notice of the meeting and requesting chat staff members list suggested items for review Two days before the scheduled meeting, define the order in which these topics will be discussed. Prepare a typed agenda for each staff member. Each months facilitator will need a timekeeper to help the group stay on schedule and avoid unnecessary tangents.

Follow the established agenda! Always carry over uncompleted old business to the next meeting. This assures the staff that you intend to follow through on all of their concerns. Loose ends should be tied up with definite assignments and responsibilities listed. Staff meetings pay real dividends when action results!

Be sure to avoid letting any one staffer monopolize the meeting. Never let your meetings deteriorate into a gripe session. Be respectful of each other and avoid interrupting when another is speaking.

Note to the doctor: Be an active listener so that staff members will increase their sensitivity to each other. Good communication is a joint enterprise. Get good at this and the benefit will extend to greater patient appreciation and understanding!

Nobody likes a complainer. However, complaining customers are one of our strongest assets. There are customers who are dissatisfied, but who never complain, and they silently take their business elsewhere. Complaining customers are telling us they care about us and our service. If they didn’t care, they’d say nothing and go elsewhere. The complaining customer is giving us a chance to keep them as a customer, and a chance to improve our practice at the same time. So welcome all complaints - we need them!

A few years ago the White House Office of Consumer Affairs did a study and found some fascinating facts about complaints:Customers who take the time to complain are more likely to come back, even if the complaint wasn’t handled to their satisfaction.

Of those who take the time and trouble to complain, 70% will come back if their complaints are resolved. That jumps to 95% if the complaints are resolved quickly.

The average customer who complains tells 10 people about their “problem.” About 13% will tell 20 or more people. This number is even higher now with social media services such as Yelp, Facebook, AngiesList, etc!!

Customers whose complaints are satisfactorily resolved tell an average of 5 people about their good treatment. These other 5 people are often prospective customers.

How do we handle these valuable people and their complaints? Here are some tips:

Let your customer talk. That sounds simple, but one of your first reactions is probably going to be to defend and explain yourself. Stifle that urge. Just listen, really listen. Pay attention and be absolutely certain you really hear and understand what the customer is saying. Don’t expect the customer to voice the complaint in a sane and quiet way. Stay calm and be patient even if they are totally unreasonable and unpleasant. You’ll be glad you did.

Let the customer know you care. Try to see the situation from their perspective. Don’t automatically assume the blame until you have all the facts. Even if the complaint sounds minor to you, it obviously must be important to the customer.

When the customer sounds like he is finished, summarize in your own words what you think they said. Ask questions which reflect your understanding of what they said. Get all the details. Ask who, what when, where, how, how often, how much, how fast or slow, and anything else you can think of that’s pertinent. This accomplishes three things: it clarifies for you and the customer what they are complaining about, it makes the customer pause to think about what he or she really means, and it gives you time to think about how you’ll resolve the complaint.

When you’re done with the last step, sum everything up - review the facts with the customer, especially if the problem is complicated. This ensures that you and the customer understand the problem.

Ask the customer what he or she would like you to do. Most of the time what they would like you to do is far less than what you would have been willing to do. Mostly, your customers want your understanding, your caring and your assurance that the same mistake won’t happen again.

Tell the customer exactly what you intend to do - even if you can’t solve the complaint immediately.

Do whatever your customers asks you to do (within reason) even if you think the complaint is not totally justified. And do it quickly. It is most important that the customer be satisfied as quickly as possible.

Don’t pass the buck. To blame someone else, even if they are really at fault, is sending the wrong message to your customer. In effect, you are telling them you aren’t willing or able to get the people who you work with to handle their responsibilities.

A final note: here is the success “secret” of a highly successful businessman: “I take all the customer nobody else wants. I go out of my way to get the complainers, the tough customers, the ones who are never satisfied, the ones who keep demanding more and scream bloody murder when they don’t get it. These are the best customers to have. For one thing, they’ve been around; they know good service when they see it and they know how rare it is. So, they stay with you. They don’t go running off the first time someone else dangles a special deal in front of them. Their friends know how hard they are to please so they tend to follow them, to take their advice and recommendations. This supplies me with a steady stream of new customers. Also, by sounding off, they teach me things about what customers like and dislike, what they think is important. But most of all, they keep me and my employees on our toes; they won’t let us get careless or overconfident for a moment.”

Answering the telephone is the most important phase of all communication in a dental practice. The patient’s initial impression of the office is formed during the first 30 seconds of the telephone contact. First impressions are lasting ones.

Always answer the phone by identifying the office and ourselves: “Good morning, Dr. Smiley’s Office. This is Alison.” By identifying yourself, you have begun on a friendly, personal basis with the caller.

Answer the phone before the third ring. Patients calling the office can only hear the ringing. They cannot see a patient standing in front of the desk, being helped. However, the patient at the desk hears the telephone and understands that it must be answered. When new patients get busy signals, they may forget to call back, or look for another dentist who isn’t so busy. Answering after the third ring gives the impression that the office is uncaring or disorganized.​Putting a patient on “hold” is a sure way to chill enthusiasm. Being placed on hold says that the caller is not important enough to rate immediate attention. The first caller always has priority, so make the second answer brief. To the first caller say, “Excuse me, Mrs. Jones, my other line is ringing. I’ll be right back.” To the second caller say, “Good morning, Dr. Smiley’s Office. This is Alison. I have another call. Can you hold for a few moments, or may I call you back?” Never answer with, “Can you hold please? (click)”

Placing a Patient on Hold:

“Mr. Jones, it may take a few minutes to locate those forms. May I call you back rather than keep you waiting?”

“Alison is on another line. Would you like to hold, or may I take a message?”

“Would you mind if I put you on hold while I tell Alison you are on the line?”

“This will take me just a moment; would you care to wait or may I call you back?”

“I have another call. Can you wait just a moment, or may I call you back?”

Personal Telephone CallsStaff phone calls are made at lunch or break time. If someone other than a patient calls the office and asks to speak to a staff member take a message and tell the caller that the staff person will return the call at their next break.

Personal calls disrupt office efficiency. If the receptionist spends a lot of time answering calls for the doctor and staff about their personal business, then the business of the practice is being overlooked. It is intolerable for any staff member to waste time on the phone chatting to friends and family. It is not acceptable to other staff members who are striving to achieve certain production goals and it is certainly unacceptable the doctor. ​